The 'Dispatched' Podcast
BioPharmaDispatch - discussing the issues impacting the Australian biopharmaceutical and life sciences sectors with Paul Cross and Felicity McNeill.
The 'Dispatched' Podcast
The 'Dispatched' Week in Review - 31 October
Reform efforts can struggle because they focus on health systems at their strongest point rather than their weakest. Framing is a pernicious tool used to justify delays and denials. We argue that the uptake of GLP-1 therapies in the US is delivering remarkable results, and that we need to apply the lessons from that experience in Australia, challenging institutional narratives and reframing the public debate to focus on public health benefits.
Hello and welcome to the Dispatch Podcast Week in Review. It is Friday, 31 October. It is Halloween. Happy Halloween, Felicity.
SPEAKER_00:It is a happy Halloween. I'm looking forward to approximately 300 children lobbying on my doorstep soon.
SPEAKER_01:Your street really gets into it.
SPEAKER_00:Yeah, it does. It's pretty cool. Yeah, you start to do it.
SPEAKER_01:I love Halloween.
SPEAKER_00:Yeah, well, you you spent a little time in the US, so you would.
SPEAKER_01:Yeah, in America, it's amazing. But but we're catching up. It's pretty good. Yeah. It's pretty good. And it's the start of the holiday season. That's what I really like about it. Because in America, it's in Thanksgiving, which is fabulous. And then you get into Hanukkah and then Christmas. And uh it's just a really great time of year.
SPEAKER_00:It's a reason that you in the US hear people talking about the holiday season. It's not to be non-denominational, it's just there's so many holidays associated with all the denominations of celebration. Yeah.
SPEAKER_01:So because it's so cold at Christmas time in a lot of the US. But anyway, let's let's get into this.
SPEAKER_00:Uh you're gonna frame it for me?
SPEAKER_01:Uh I am gonna frame it. As you know, I've been banging on about framing this week and maybe it's a source of frustration, but I've sort of been on this higher level critique most of 2025. Yes. You know that I believe that stakeholders make the mistake of attacking the system at its strong points.
SPEAKER_00:They do.
SPEAKER_01:The system, the institution is very smart. And they they faint. You know, they not F-A-I-N-T, but F-E-I-T. F-E-I-T. F-E-I, but they they they show their vulnerabilities at their strongest points. Yes. The classic example being the HTO review. That's you know, like the pig in the proverbial. They're happy they're happy fighting on that turf. Very happy. It's the high ground.
SPEAKER_00:What's the greatest joy a HTA bureaucrat can hear? We'd like to discuss the discount rate and comparative erosion.
SPEAKER_01:I'm not saying I'm not arguing that they're not problems. I'm just saying that it's not the way to come at them. The way to come at them is to make the intellectual case against the system. And unfortunately, a lot of what passes as advocacy often has the inadvertent, unintentional effect of actually legitimizing a lot of the mythologies around this system.
SPEAKER_00:Yeah.
SPEAKER_01:And you know, I've written about it this week, so I won't go into it, but one of my one of my massive frustrations is the issue of framing.
SPEAKER_00:Yeah.
SPEAKER_01:And I and we saw it in New Zealand when that New Zealand Treasury official gave that laughable presentation. And even she sort of admitted, well, that's probably not going to happen, where you had the New Zealand government spending and revenue line sort of tracking pretty closely together until 2030. And then at 2030, the spending line took off like a Concorde taking off.
SPEAKER_00:Yeah.
SPEAKER_01:And that's framing.
SPEAKER_00:Oh, you mean a bit like um which your listeners, I think even Medicines Australia talked about this last year when the most recent IGR was released. But when in 2002 the government framed the growth of the PBS that was going to be, well, four to six percent of GDP by 2040 to 41. Sorry, I exaggerate. It was going to be 3.4% of GDP. All pharmacy spending. That's what we're doing.
SPEAKER_01:Yeah, it's going to be like$40 or$50 billion by now.
SPEAKER_00:Yeah, so it was going to be from a 0.6% GDP in 2001, too, as a percentage, to 3.4%. Now, what did that do? That was the trigger point, as you know, for us starting to introduce measures.
SPEAKER_01:Was the big savings package, came the day after? It was a political construct.
SPEAKER_00:It was a political construct that then continued. And you know, it's it's funny about how important that framing is, and you love it how we continue to always talk about sustainability of the PBS, opportunity and responsibility. But how important is that framing? And you consider that 20 years on, the actual percentage of GDP that the PBS represents, and this is gross, so before you take out the um you remove it, the uh whatchamacallit? Rebates. Rebates.
SPEAKER_01:Revenue.
SPEAKER_00:Revenue. It's actually lower than it was. So in 2002 it was 0.6% of GDP, and in 2023 it was 0.47% of course of GDP.
SPEAKER_01:You being an ex-finance official, you would know that they would say, well, that well, that just goes to show how good our response to that IGR, if we had done nothing, if we had done nothing, imagine what would have happened to the city. I know exactly what it was. It proves the importance of that IGR.
SPEAKER_00:It it is, and like you said, they were estimating that we would be spending 41 to 42 billion dollars a year on the PBS in 20 the most cut 2023, 2024, and we spent gross 17 billion. Now when you take out all the rebates and all the things, yeah, we're we're still around 12 billion.
SPEAKER_01:So Brendan Sure and I still laugh about that first IGR.
SPEAKER_00:Look, you know, but what's important about it, and this is why you want to talk about the framing, if you frame it right, if you time it right, and the system and the stakeholders don't react to it with the right amount of incredi incredulity and pushback, it becomes the new dogma, and everything is done through that lens, and it takes you decades to try and have a different conversation for access, which goes to your point of framing. And I know you wanted to talk about some um obesity.
SPEAKER_01:Yeah, so in 2002 the industry did not push back on it.
SPEAKER_00:No, you didn't.
SPEAKER_01:They the industry because I was in government at the time. I can remember when that IGR came out because we had not seen it. No. I was in the health minister's office, by the way, and we had not seen it. So I called what your one of your FAS predecessors and said Excuse. Yeah, what why haven't I seen this? He said, Why haven't you seen it? We haven't seen it either. No, you didn't they didn't consult you on this? And he said, No. And I said, Okay, we've been set up here, aren't we? He goes, Yes. It was a bit like the uh the National Commission Award when Health wasn't consulted on that, that one either.
SPEAKER_00:But when they went to see Farmax.
SPEAKER_01:Yes, when they went to see Farmac secretly. So yes, uh I would recommend people at least read the transcript of Eli Lilly's third quarter investor update. Go through the slides, but read the read the transcript. This this this this is a this is a presentation of historic significance. And we can look at the financial performance, and I'm gonna get to the framing issue because it's very localized here in Australia, but sales of GLP1 medicines doubled in the three months to the end of September compared to the globally, compared to the corresponding period last year. So from roughly 5 billion US to 10 billion US, so around about 110 million US every single day. Three-quarters of those uh sales outside the US are for weight loss, not diabet, not diabetes, and are uninsured. It's 100% basically out of pocket. The company, it was a very good, it was a really informative presentation because it made me realise that when it comes to GLP1s and weight loss therapies, we are very much at the end of the beginning, as Churchill said. Uh they are developing a whole portfolio of medicine. So they've got the their current GLP one products, and they're for people with obesity aiming to lose 15 to 20% of body weight. They've got the very much anticipated oral GLP one, and that's going to be the way they were talking about that was in terms of maintenance therapy. So uh these are people who may have been on the injectable and they go onto onto this, or they're people who don't have the really high BMI. Obviously, there's a lot of advantages in terms of a tablet uh in terms of ease of use and potential cost, but they're also developing a triple combination therapy, which is for really uh uh people with very high BMI aiming for significant weight loss. So they've got a whole portfolio of products here. So this this is this was really interesting. So the stats in the US one in eight adults has reported taking a GLP one for weight loss. One in eight. So that equates to uh approximately 32 million people, which is pretty staggering. So that prevalence has more than doubled. So the the the number of Americans taking a GLP one for weight loss has doubled in 18 months, which is absolutely staggering. So is it working? Well, yeah, it appears to be. So in terms of reversing the trend, so in 1990, 23% of US adults were considered obese. That rose to 30% in 2000, 35% in 2010, 40% in 2022. It's fallen to 37%. So it's fallen in in absolute terms by around about 10% in the last few years. So that's that's a pretty that is that is a that is the reversal of a five decade old trend.
SPEAKER_00:Yeah.
SPEAKER_01:So that that's pretty amazing. So we really need to think about that, and I'm sure in the US they will be thinking about, and one of the weaknesses in the US health system is that public health analysis. It's not it's not great, but but but they do have a a lot of think tanks and universities and public health schools that will be thinking about the population health benefits of this dramatic weight loss that we're seeing across the country. Now we can be a little bit condescending about you know weight in the US, obesity in the US, uh people in glass houses, so their obesity rates have declined to 37% as a result of GLP ones. We're at 32%. So we need to get on this. I believe we need to get around this from a public policy perspective. You know, we if you look at like for like, you know, we might there's probably several hundred thousand Australians currently taking GLP ones. I don't know because it's existing outside the institutional framework, we can't really know. I'm sure Lily and Navon Nordists know. But on a population basis, if you're looking at like for like, US or even the UK, where they say around 2.5 million people are on them, their obesity rates are lower than ours. We we we should, you know, like for like have one to one point five million people taking the GLP one. And I don't think we should feel badly about that. I don't think we should be concerned about it. I think we've got to start thinking about it in terms of what is the public health good. And I am going to quote him because I caught up with Andrew Wilson a few years ago, former PBAC chair, currently leading the HTA review implementation group, and he said to me, Paul, you know the thing about these weight loss drugs? They work is they work. And and I think that the evidence coming out of the US shows that they they do work. Now, what's the level of discussion in Australia? Well, we had that idiotic article on the ABC news portal last week where they sort of decrine disease awareness campaigns. Like, dude, have you heard of this little thing called the internet? If I want to find out information about weight loss therapies, I do not need to worry about a disease awareness campaign. That's probably not going to appear in my algorithms. That's true. Or an awareness campaign. It's not going to appear in my my algorithms. And I don't really watch free-to-wear TV because no one does these days. So I I I I only saw the I only saw the ads because the ABC showed them. So that was pretty disappointing for me. If you do a basic Google search, their AI generative tool will give you the list of products, their regulatory status, and how you can get them. That's really helpful. So forget about these arguments that belong in a time capsule. The more concerning thing for me is the way this is being framed in Australia. The ministerial request to the PBAC, which I suspect was, Minister, you should probably write to the, you know, how would you feel about writing to the PBAC to get their advice on making these available? Very small. They're going to be looking at niche populations, targeted groups, in which case the risk to me is that we're considering it in this outdated view. We're not really appreciating the historic significance, the potential social benefits, broader societal benefit of these therapies because they are we're seen in the US now. And we should be thinking about it in those terms. I I believe we should be thinking about it in those terms. And so we need a bit of a bit of innovative thinking here. I think the companies can could contribute to this intellectually to address the framing because the risk is that you've got this huge private market, a private a market we've never seen in Australia on any product like this. Huge private market. But obviously, only some people are able to access it in terms of cost. They might decide that, well, let's, you know, let's make it available for these niche populations, and if we we can all guess what they will be, we don't need to everyone will know what those populations will be. They'll be small. Will the companies be willing to do that? I don't know because of the potential risk to the private market. Who knows? We'll wait and see. But again, it's been framed as if we do this, the system will explode.
SPEAKER_00:Yeah. So um you you talked very sagely about the framing and why why this matters and your concern about inequity. So if we go back to Australia's national obesity strategy, 2022 to 2032, so we're three years in, one of its goals is for more people to maintain a healthy weight through achieving two targets. Halt the rise and reverse the trend in prevalence of obesity in adults by 2030. The second one's about children. Implementation will be guided by four principles, one of which is creating equity. What the strategy doesn't really talk much about is the medicines themselves. But let's let's put that to that moment. That's apparently what we should be doing. So when you're talking about the fact that people decry that obesity is a crisis in Australia, that it leads to comorbidities of everything from renal, cardiovascular, diabetes, all these other problems, let alone the burden on the acute care setting, uh, lack of productivity, etc., etc. So we talk about it as if it is the greatest crisis facing our country at times. And yet this is something that when it comes to these weight loss treatments, we do a go slow on. And to be really clear on how much the system is using delay, they are doing pay for delay, they're just paying to delay. And I remind everybody that we had a diabetes inquiry announced in May 2023. It wasn't really about diabetes. Although we used that cover, and when you talk about framing, we said that the House of Representatives should look at the causes of diabetes, type 1, type 2 ingestational in Australia, including risk factors such as genetics, family history, age, physical inactivity, other medical conditions and medications used, new evidence based on the prevention, diagnosis and management of diabetes, the broader impacts of diabetes on Australia's health system and economy. And then the thing that is actually what this was really all about. Any interrelated health issues between diabetes and obesity in Australia, including the relationship between type 2 and gestational diabetes and obesity, the causes of obesity, and the evidence base in the prevention, diagnosis and management of obesity. This was a framing to delay the issue that but at that stage in May 2023 we had a huge number of these medicines coming forward. Huge number, and the system was already starting to say no to them. We then put everything on hold because when the Parliament's reviewing something, we couldn't possibly take any action on anything. We had the report released in June 2024 with 23 recommendations, one of which related to perhaps you should consider GLP ones for tackling obesity treatment in Australia. Mind you, there were 22 other recommendations, which also included expanding insulin pump access and something else that's been framed today with the release of the Medical Services Advisory Committee outcomes on their consideration of one of the recommendations from that inquiry, which was to make continuous glucose monitoring available for anybody who has insulin-dependent diabetes, whether it be type 1, type 2, or type 3C, which for people who don't understand type 3C, it's usually associated with um cis uh diseases like cystic fibrosis uh and other areas. Now that's come out today and it's been framed as deferral, but it kind of reads like a rejection. It's been framed as this is going to cost us a fortune because you know everybody with type 2 diabetes having access to CGM isn't financially viable. But hang on. I actually had to read the applications from the companies to realise that they didn't ask for all of type 2 diabetes. They just asked as per the uh diabetes inquiry, uh which are now 15 months old, which is for insulin dependent. And like you said, they are quite explicit about subpopulations that we should consider providing access to for this technology and again false framing. Yep. Meanwhile, all 23 recommendations from that inquiry are all still sitting in abeyance waiting for for some intervention or some response. But it goes to this issue of how the system frames things, and and you're quite right. When we've got a national diabetes uh obesity strategy that says we're worried about equity, what you're raising here is there are those that can afford to pay for it and there are those that will not be able to afford to pay for it. When we talk about, for example, diabetes, it's more prevalent in remote and very remote Australia, three times more likely to be ha having type 2 diabetes there than in the rest of Australia, and twice as likely to die from it if you live in remote and very remote Australia as opposed to anywhere else in the country. So when you then start to talk about subpopulations about which are not going to be based on where you live, because that's not what uh MSAC recommended by reading some of those materials, we are framing to a very different difficult place of haves and have nots, as you said. And yet if you read the National Diabetes uh obesity strategy and our genuine concern for we have to we have to arrest this this prevalence, this this crisis in our country, and it's all about you know, exercise more, eat more green vegetables, um, you know, let's educate you more to be better people, as opposed to hang on a minute, like you've said, there is a medication right now that can change how your body responds to food, how you get healthier, how you control your obesity, and thereafter can do all the other things that the obesity strategy tells you to do get fitter, do more exercise, eat better fruit and vegetables, etc. But you're completely right. We have all these different things going on, all these different framings, and I can point to one thing and look like I'm a very noble, you know, focused government in public health, and then you can sit here something with all this information, and it comes down to stigma, which is oh, well, that's just being lazy, you should lose the weight. We all know that's what is going on here. And yet, if this is what gives people a better health outcome, we don't say, I'm sorry, but you know, you smoked and you got lung cancer, so therefore we shouldn't screen you. Oh, we do. Um, oh, and we shouldn't give you the cancer treatment. Like, come on. Like we're gonna be able to do it.
SPEAKER_01:We don't have a punitive health system. I mean, that's never been the case. It's why we we distribute free needles for injecting drug users, because it's just the greater good.
SPEAKER_00:Yeah.
SPEAKER_01:And sixty-five percent of Australians are considered overweight, and about half of that group, or more than half of that group, is considered obese. So what what what bothers me is the inability, our apparent inability to have a conversation b beyond this silly framing that that positions every new technology in terms of its ability to collapse that the the the country's fiscal situation. And as I wrote this week, it's this idea that well, me me wanting to get access to innovative health care is against the national interest. That's essentially what they're saying, which is which is utter nonsense. And I and I actually think there's a moral element to this argument in that it is immoral for people to do this. I certain certainly question the morality and the ethics of an advisory committee misrepresenting a submission outcome for the purposes of framing. So I I I object to that. I think we are capable of having a meaningful conversation about this. Might we need to spend several billion dollars a year on these weight loss therapies? I'm not saying that spending on them should be should be reckless. I'm saying that if if you went to these companies and said we want as many people who qualify with this group to access these products, what's the best price? I'm pretty sure you could negotiate a very, very good price deal. I think the that consideration should be given to having these outside the PBS, even lots of different alternatives. All I'm saying is that the instant instinct to frame these products like all other innovative technologies like CGM. As someone who's used CGM, I don't have type diet, I don't have diabetes, but I wanted to use it and I found it very I found it incredibly informative and easy to use, just amazing technology. But but this this instinct to just instantly present every new healthcare intervention as a potential doomsday scenario or a catastrophizing it's it's just to me it's like come on, and I think this is why people have to challenge it, and I do think it's an opportunity for advocates in this area because look, we've been telling people to exercise more since the 1970s. When did Life Bunit start in the 1970s? I can remember going to the 20 25th anniversary of the Life B init campaign in the 1990s. That's a whole nother story, but yes. All the evidence suggests it is having quite a rapid and remarkable impact. Now, I'm sure the companies over there and healthcare think tanks, they're all gonna public health schools, they're all gonna get into well, what is the wider population health benefit and the health system benefit of getting these people out of other parts out of inter doesn't mean there there's less less interactions with the health system. Doesn't mean that. If if if that is the case, what does it look like? And is there potential for us to mimic that here?
SPEAKER_00:And that's exactly right. And so again, I'm going back to the national obesity strategy, government's words, which based on consultations with 279 odd groups, so must be good words. Without further action, we face a future with more weight-related chronic diseases and earlier death, greater vulnerability to infectious diseases, and significant costs to health care, economic development, and community well-being. The coronavirus pandemic has shown it that people with obesity or chronic diseases get sicker and are more likely to die from infectious diseases. There is also evidence that COVID continues to influence Australians' eating and sedentary behaviour patterns. Australia has committed to the WHO global target to halt the rise in overweight and obesity. This focus presents us with an important opportunity to make significant improvement in the lives of Australians. Without government leadership is critical, governments cannot do it alone. Government, industry, the community, and individuals all need to take action. We must all work together on integrated actions that complement each other. Okay, so we've spent a fortune and we spent years negotiating this because we decided that this is an economic and health cost beyond the cost of obesity itself. So we have to have that sophisticated conversation. And yet we are allowing, through the way the PBAC has had a particular issue referred to it, we have allowed the framing, the disaggregation of the obesity strategy from one of the really important tools that could actually help with that. And the question we should all be asking is why? Why are we not forcing governments to frame back to that moment and to say, no, you don't get to pick and choose? I mean, as someone who's still reeling from the way MSAC framed newborn blood spot screening for Pompeii disease, which is if you screen for Pompeii and we get a false positive or we find out that it might be non-infantile onset, but but later onset, that causes too much distress and and horror for the families. However, if we do the same thing in two other diseases, that's perfectly acceptable and a really good way to go forward. I've watched MSAC frame out one disease from newborn blood spot screening. I know what this feels like, and I know how hard you have to keep fighting. I had it had an election commitment to actually do it. You have to argue against the framing.
SPEAKER_01:You have to You've done accept it.
SPEAKER_00:Like you have said, that the weakness of stakeholders is that they accept the government pointing them to attack them at their strong point, not their weak point. And that's what you've got to go after. You've got to go for the jugular, not because you're a mean person, but because it's your job as an advocate. It is your job as industry to find a way forward for the community to make the system look after the community that actually pay for it.
SPEAKER_01:Yeah, I don't think anyone should accept all of those issues just being dragged down into this doomsday vortex. It's completely ridiculous. And uh that requires people to take the system on and these decision makers on intellectually. And I and I actually don't think, you know, as I said, I think it was yesterday, Australia spends$270 billion a year on health. Two-thirds of that is government, the other third is a combination of health insurers, private consume, you know, private out-of-pocket costs.
SPEAKER_00:And growing.
SPEAKER_01:Yeah, yeah, well that's the that's the bit that's growing. And the risk is that if we don't say, well, let's divert some of that into these areas around innovative technologies, then what's going to happen is this uh ecosystem of private health care. And I'm not talking about private health insurance, I'm talking about private out-of-pocket costs for treatments, innovative treatments that are not available within the institutional framework, will continue to grow and it will be accessible to high-income earners, well-educated people who are aware of their options, and people who are confident to in engage with the health system on their terms.
SPEAKER_00:And it's fair. And you know, Australia unfortunately has a history that when something is too much funded outside in the private sector, as in not private health insurance, and out of pocket by people who can afford versus those that can't, it does eventually start to move. I mean, we've seen that with activity-based costing in the hospital, state hospital systems. That's that's a response to how many people were paying for things outside of the system. If you think about newborn blood spot screening, I'm being advised and lobbied quite a bit to say, you know, the only way to to make this government move is to do what they hate, which is to actually find a way to privately provide newborn bloodspot screening through in Australia for families to pick and choose. And maybe the private health insurance will cover it, or maybe you know, mums and dads will do it out of pocket, they'll pay for it out of pocket. Because that's the one thing we have noticed that makes the minister nervous, which is, of course, as he told the ABC, which you were reading to me earlier, you know.
SPEAKER_01:he if he can't get the the the doctors to agree to to bulk bill he'll he'll bring in his own doctor it's gonna nationalise GP's like what's just madness is he's gonna give them a free chance of battery that was that was absolute madness where he says if doc oh if clinics do not embrace this bulk billing incentive they will provide other financial incentives to other practices to relocate to those areas so you're gonna be directly funding competitors to private sector providers of primary care what what and the fact that the GPs organizations don't go straight to the mattresses can you imagine if you said that about pharmacy oh yeah can you imagine Trent you need to go and teach these guys how to do this can you imagine and the GPs this is this is this is this is madness but we know that the instinct of public health policymakers is command and control. You see that in AI where they talk about guardrails mean why everyone's just going off and doing it. In fact I suspect some of the some of the companies that are distributing these weight loss therapies are employing a lot of AI tools.
SPEAKER_00:Yes.
SPEAKER_01:Which is fine I have absolutely no issue with it. So uh I wonder to what extent our public health policymakers have any understanding of how big this market is and how big it's going to get incredibly quickly. So if you look, you know you could probably say that we're following the US now we don't have direct to TV advertising like they do in the US I mean I'm sure these GLP ones are absolutely smashing it online and all sorts of things. We don't have that so we have these disease awareness campaigns or awareness campaigns which are a little bit hard to understand and hard to access yeah hard to access much harder in Australia but you've got to think that we are just sort of following the US so would it get to a point where 12% of adult Australians are well I don't think it's unrealistic. No I don't think it's unrealistic particularly as awareness grows accessibility grows and and the technologies this oral one I mean Lily confirmed on the on this call that they have already produced billions of doses billions ready for distribution. So the the my my concern is that whilst the private market is and I you know I'm I'm all for private market in health I think it it improves the system generally however the government has to get its head out of it you know where and understand that you have to respond to it you have to respond to that and if that means breaking away from this silly framing around virtually no one is going to get subsidized access to it and we know who will who will and who won't. Read the M second twice a good idea of people and then they'll be able to say oh but we are funding it for high risk popul high need populations meanwhile you're gonna get millions and millions and millions of people in the middle who miss out.
SPEAKER_00:Yeah and look I'm I'm gonna put my my finance hat back on again and even partially my health hat I get sitting in the finance portfolio the abject fear of these medicines because we are how long do people actually have to stay on them and and do you need to stay on it to maintain. So if we all recall the biological DMAs, the disease modulators for musculoskeleta which are now in also gastrointestinal those were originally recommended for listing based on the fact that you needed to be on it for a couple of years and then it was fine. But then of course we realized that a disease modulator it's not like a gene therapy for like SMA it's a disease modulator you've got to keep modulating the disease and so people need to keep taking the treatment and I think that when you're a public health sorry not public health but when you're publicly funding purchaser that is what makes these governments nervous and what leads the HTA bodies to hunker down because they don't believe you know I'm gonna get this person who's got a BMI of 31 and I'm gonna get them down to 24 and then I'm going to withdraw the treatment after you know what what's that nine months, two years and will they balloon back? Can they actually control it? Are there side effects do they become more sensitive to insulin thereafter and have they a higher prevalence of diabetes? That is how a HTA system creates huge uncertainty some of which is real and some of which is how I forecast and fear that to well I need to discount for that uncertainty. I need to factor in the fact that it's not going to be a permanent cure it's going to be everyone's going to need it for you know lifelong treatment. So you know are you going to need constant like top-ups now as you were saying about the Eli Lily product obviously the um tablet form is going to be the replacement for the GLP ones once you've actually stabilized. So how do we actually bring that together? You can still give a subsidy for that first off two-year thing I mean we fund bariatric surgery for the same reason because we say we need the intervention and the losing weight is the most important and it's very effective. Very effective. So if that is effective and and I think that this is where the HTA systems will try and compare apples and oranges which is I know if you do bariatric surgery one of the reasons that's very effective is is because we basically make it impossible for you to eat that much food. There's just not that much room. Whereas the the weight loss drugs, the treatments are attacking the behavioral outcome and how your body responds to certain chemical and neurological responses. Will that maintain or will you fluctuate will you rebound and will I be paying for these medicines for the rest of your life and therefore that's the tension point. And that's the tension point that we use to delay. So it's the same thing when you read the the medical services advisory public summary documents on other things that have come out of the diabetes inquiry. It's where does it end? How long do you use it? You know, can we just use it for a short time rather than a long time that's where the system is genuinely concerned but also uses that concern to amplify to the point that it means we can't do anything and we need to attack that.
SPEAKER_01:Yeah.
SPEAKER_00:I mean why couldn't we just have you've got a you've got an entitlement to 52 weeks.
SPEAKER_01:I don't think that yeah I don't think they understand markets though. They understand capitalism.
SPEAKER_00:No.
SPEAKER_01:So if you're an investor or if you're another pharmaceutical company and you see that Lily's on track to generate something like$50 billion over the next 12 months from sales of GLP ones globally fair chance you're gonna start looking to invest in other GLP ones which is exactly there's a mad race there is I just a mad race amongst companies to get into this technology. Where where where I believe our system is ineffective this is the irony the irony is that they're not historically really good at taking advantage of competition within patented frameworks within single brand frameworks and the BD Mud's actually an example of that. Yeah so yes at the moment Lily and Novo Nordisk are dominating this space but in two or three years time I know there are Australian biotechs getting into this space. I I I there is going to be so that you have to think that the investment will be so attractive and irresistible that companies are going to be plowing in and I know Pfizer's in it like they're all they're all looking and all diving in. So that's going to create more and more options and so yes it might cost a lot initially but the price will fall if you if you get the policy framework right. And so my concern about this is one of equ equity is that the people who can afford it are going to get it and some of those will need it and some of them won't and niche population groups will be able to get them whether they do who knows what the uptake will be because they've got to be able to get access to doctors you know there's I think there's an argument to put those products through pharmacy to be honest like they're talking about in the UK and you're gonna get millions of people in the middle who desperately need weight loss don't live in a public health fantasy world where they can go to the gym three times a week and go for walks and you know because you know the r the reality is you know you've got a lot of people who might qualify for these therapies who are on median incomes are bringing up children have comorbidities or injuries they have to work they've got long commute times. I mean I'm sorry life in 2025 is pretty complicated and there are a lot of demands and we have to be reasonable in what we expect of people and my concern is that millions of people are going to be excluded from this because of a lack of innovation around policy and a lack of commitment to discuss innovative policy solutions. That's my concern and it's not just GOP ones that is the headline example because what we've seen in US which is it's a staggering turnaround there. It is staggering where they've reversed a trend yeah my concern is that it's it applies to all of it applies to CGM it applies to insulin pants which are getting harder to access all of those fantastic technologies and and as I sort of have said recently and I sit in New Zealand and I I've written it's like I don't I don't Australia is not a cheap we shouldn't be cheapskates on this stuff. We choose to be cheapskates we choose to be and it doesn't make any sense to me it's not like you know we what we can't but the way it's framed is if we fund this the world our fiscal realities will collapse because we've just gone we've spent on the NDIS has gone from five billion to fifty billion in 10 years. Yeah okay the world's not collapsing as a result now I'm not saying reckless spending I think we can afford to spend a little bit of money and even even if you make these more widely available for people and you have some innovative ways to do it not everyone who qualifies is going to want them. That's the reality. So we need to be just think practically practically about it.
SPEAKER_00:And and we need to like CGM. Yeah but we need to be ethical about it. So and that this is the thing that frustrates me. You cannot lecture the community with a national obesity strategy and say it's it's you know the end is an eye for us and then completely set that aside because you don't want to discuss it because it might lead to some having to invest money here. Well is it a problem or is it not? Because if it's not a problem if it's not a and if if you try to say it's only a pop a a problem in small subpopulations then you should burn not that we print anything but you should get rid of that national obesity strategy because it's a lie. Because if that document, if you're not willing to contemplate broader access to treatments for weight loss control and weight loss information based on that national obesity strategy, it should not exist. And this is where stakeholders don't call governments bluffs and say you spent how many million dollars putting that that PDF together and consulting how many groups and things and coming up with all these ideas? I would happily say do you know what let's take money out of the MRFF and whack whack everyone on that.
SPEAKER_01:Just make it a massive clinical clinical trial I still don't understand the criticism of what's going on the MRFF to be honest.
SPEAKER_00:But yeah me neither but if that's the if that's the way you want to do it then put all of Australia who who qualifies for the for these things on a on a on a two year clinical trial and then take the data and thereafter use that data to say from here on moving forward this is what we'll fund.
SPEAKER_01:Yeah it's just it's the classic framing exercise it's frustrating for people like you and I we both know that governments get terrified at these things but they go straight into exaggeration mode. Now I I I always say to people how many Australians are on cholesterol iron medicines on statins these days? Three million, four million?
SPEAKER_00:Well we have been regularly asked to just put it in the water it'd be cheap.
SPEAKER_01:Yeah but can you imagine can you imagine the challenge that they would have in 2025 getting through the HTA process compared to what they dealt with 30 years ago 35 years ago. Can you imagine how hard it would be oh yeah because what there's a there's a potential population of three million so we'll fund 3000 what happened until the the big study the like the heart protection study came along and showed that it should be in the water at Oxford that one of the biggest clinical trials of all time but but it's and so they had to do it eventually but I I think these days the systems would the system would be very less receptive to it. Well the consequence of that is a decline in health system equity. Now I know that the government is a big believer in health system equity when you go to the GP but nowhere else let's be honest. But but nowhere else and I think we've got to be innovative in our discussion about this and I'm West Street in the UK the health secretary in the UK has been very innovative about it. They know it's going to cost a lot but they're trying they're trying lots of different things and one of the things he's talked about is because they've got a massive issue with people who are able to work and don't work. Yeah basically they're they're they're on disability benefits or something but really they can't they can work so he's talking about that population it's a ridiculous number he's talking about that population and he's talking about well okay we can't have this rush to GP so let's think about giving it to pharmacy let's make it but make them available through pharmacy why don't we do that why don't what why do why can't we think about innovative models and if it means that we need to think outside the PBS then let's think outside the PBS let's create partial subsidies let's get PHIs to do it. I don't I don't like there's lots of different ways but you'd have to change the fee structures and everything and they'd probably run from the building like it would be on fire but create the incentive think in a innovative ways to do it because ultimately PHIs will be the big beneficiary of the population health reduction but the population level reduction in obesity because of obviously all the surgical interventions that are required. So there's a lot of ways to think about it and I think that that's that's the opportunity but yeah framing.
SPEAKER_00:It's good to talk about framing on Halloween because it is a complete nightmare yes wow yeah that's pretty good you just like came up or have you been working on that whole thing? I had that one in the holster oh well done you did but the way you delivered it I never get messed up that's right.
SPEAKER_01:Thank you Felicity thanks everyone we've got our AMA summit in just over a week the program has come together really really well we're adding a couple of things over the weekend one is one of private health insurers going to talk about some of the work they've done and it is really really interesting and uh sort of plays into plays into this conversation so I'm really looking forward to that and to seeing everyone there. Happy Halloween bye